Skipping Your Period and Google

I don't know if this is a common blogosphere occurrence, but I must say I receive the most interesting questions. A reader wanted to find out more information about skipping her period, or menstrual management (MM) so off to Google she went. And this is what happened:

90% of the results are about menstrual management for developmentally or intellectually disabled women! In fact, in the first three pages of Google hits, the only non-disability-related results are related to you; they all point to this blog or sites about your book.

I realize the menstrual management idea is relatively new and all, but is handling disabled women really the only context in which it's been discussed until now? Nothing about non-disabled women who just don't want their periods? I'm just blown away.

Actually, I had the same reaction when I discovered the dearth of MM information available to women; hence, my decision to write the book. While we wait for it to come out, let's try to fill this informational gap a little bit by, briefly, going over who can benefit from using MM, and then by looking at why you (and, apparently, Google) don't have enough MM information.

Before we start, I must nip this meme in the bud: the MM idea is relatively new. No, it's not! The only thing that's new is women *finally* getting some information about it.

First, the Pill was initially FDA-approved as a MM drug (in 1957), not a birth control one. That came later, in 1960. Second, using hormonal birth control to treat period-related problems (e.g., endometriosis) has been the standard of care for decades. Third, studies of women using the Pill to suppress the monthly [fake] period have been published as far back as the 1970s. [If you think the concept of Seasonale/a trimonthly bleeding episode is new, think again. The women in a 1977 British study used a similar, trimonthly regimen. Interestingly, 82% of those women welcomed the reduction in the number of periods.] And last, but not least, everybody from honeymooning brides to students, and farmers--women with no period-related problems--have been using MM for lifestyle reasons, also for decades (provided their physician was familiar with it). Apropos of physicians: a 2003 Gallup poll commissioned by ACOG (the American College of Ob/Gyns) found that female ob/gyns are nearly unanimous (99%) in the view that menstrual suppression--the daily use of the Pill to stop monthly periods--is safe for their patients. More than half of women ob/gyns have tried menstrual suppression themselves.

Bottom line: MM is not a new idea. It's been in use for decades.

1) Who can benefit from using MM?

A. Women who don't want to have monthly periods

(because they simply don't like to or because they live in societies that consider menstruating women "untouchable")

B. Women who lead an active lifestyle

(women in the military, women who enjoy active sports, women with physically demanding jobs--stay-at-home mothers taking care of small children, shift factory workers, residents and nurses, mail carriers, etc.)

C. Women with period-related health problems

(cramps, heavy periods, endometriosis, seizures, etc., as well as women with various disabilities)

D. Nonmenstruating women

(women using hormonal birth control no longer have menstrual periods, yet they still experience fake period-related health problems--cramps, migraines,etc.)

One important note: there's no connection between sexual activity and using MM. In other words, MM can be equally beneficial to nuns and mothers of five children. (So, if you had any naughty ideas, nice try, but no.)

Bottom line: although disabled women are one group who can benefit from using MM, they're just one of many. In fact, non-disabled MM users are the clear majority. So then, where's the MM information for non-disabled women? Apparently not on Google.

One thing just occurred to me: most physicians who know about MM aren't probably even aware that this information isn't widely available. I certainly wasn't until something happened--I looked for a good lay MM book to recommend--that made me joltingly aware. [In my colleagues' and my defense: I think we live in a bubble. The lay people we come into contact with, our patients, know about MM because we tell them. All the rest, co-workers and friends, also already know since the majority are medical professionals.] As to the health care professionals who don't know about MM, as well as women in general--how can they be expected to be aware of an information shortage when they're not aware the information exists to begin with?

2) Why isn't MM information widely available?

A. Health-care professionals

(too little time spent with patients, some don't know about MM, etc.)

In a survey of nurses and physicians, 43% said they don't prescribe MM drugs because patients don't ask for them and 4% don't prescribe them because of the extra counseling time involved.

B. The government and pharmaceutical companies

(bureaucracy, no interest in changing drug designation from off-label to "on-label", etc.)

A quick primer on the impact of an off-label designation. First, what do "off-label" and "on-label" mean? Here's an example: the antidepressant Zoloft is FDA-approved for treating depression. This is an "on-label" use. [Once a drug is FDA-approved, for whatever indication, physicians can prescribe it for another indication.] While using Zoloft, physicians notice that it's also very effective at treating premature ejaculation and start using it for that as well. This is an "off-label" use. Most drugs are used off-label, and the off-label use is often considered the standard of care. Only drugs that are FDA-approved can be used off-label.

How does the off-label designation impact you? In a major way. It keeps you out of the loop by law. Pharmas are not allowed to distribute information about off-label use directly to consumers. Most often, they don't even volunteer the information to physicians (they can, but usually, only if the physician initiates the inquiry). Unfortunately, since the drug is already FDA-approved and the physicians are already using it, legally, off-label, the drug manufacturer has little incentive to invest in changing the drug designation to "on-label". In other words, there's little incentive to keep you informed.

For example, before Seasonale was FDA-approved in September of last year, MM use of the Pill, although the standard of care, was off-label. In practical terms, this meant that, unless your health-care professional new about MM and elected to share the information with you, it would've been very hard for you to educate yourself about MM. Now that Seasonale is "on-label", you can get some MM information. As in, you can get information about Seasonale and nothing else. Not the over 10 other monophasic Pill brands* with the exact same composition as Seasonale, not about using a triphasic brand for MM (despite the fact that, according to the manufacturer, a triphasic brand is the one most used by American women), and most certainly not a peep about using NuvaRing, the vaginal ring, or other hormonal methods for MM. Remember, only Seasonale is "on-label"; the rest, although identical in the case of the other monophasics, are off-label. And you're not allowed to know anything about them, under threat of great physical harm. [I'm joking, of course. Or am I? After all, it's quite possible your pretty little heads will explode now as a result of exposing you to all this information.]**

C. The media and society

(the message that the menstrual period is more disgusting than any other known and widely advertised body function--acid reflux, gas, impotence, etc.; acceptable to discuss anal sex, vibrators, decomposing bodies, while mentioning the period, not so much)

*Monophasic Pill brands equivalent to Seasonale (same hormone content, different packaging):

Seasonale estrogen 0.03 mg + levonorgestrel 0.15 mg
Femigoa
Femranette
Levlen
Levora 0.15/30
Microgynon 30
Minidril
Monofeme 28
Nordette
Ologyn micro
Ovranette
Stediril 30

*Just so you know, in the book all you get is the actual data. The purpose of the book is to give you complete and correct information about MM, to allow you to know more and live better. It's not to expose you to my personal comments and opinions. Despite their brilliance, they're irrelevant to your health decisions. [That's why I have a blog, in case you were wondering. Wouldn't want to deprive the world of my opinions. And that's also the reason I blog more-or-less anonymously. I'm quite uncomfortable with physicians expressing their personal views right alongside medical information.]